It’s not often that non-healthcare startups make it to the review list at Multiplyd. But the recent news about cloud storage mega-startup Box moving into healthcare is too tempting to ignore. Let’s first talk about what Box does, and then dissect it’s applicability to healthcare.

Box is a cloud storage, file-share-and-sync company. It claims more than 8 million users and has taken about $284M in funding so far (yeah, that’s right.. >quarter of a billion). With that kind of hormonal surge, it wants to grow up. Fast. And become an enterprise storage company, beating some of its rivals to the punch.

Last month Box announced that they are embracing healthcare, HIPAA and all. “That’s gutsy..” was my first thought. It’s about time we created some of the fundamental building blocks for modernizing healthcare IT – storage, communication, mobility, scheduling, collaboration, pricing, discovery, to name a few on my wishlist. No doubt we need broad disruptions like this in healthcare. If companies like Box solve a fundamental infrastructure problem like storing PHI in a device-agnostic secure platform, it’ll take away some of the complexity of developing for healthcare. More innovation will certainly ensue. The healthcare partnerships Box kicked off with are already some of the young disruptive startups in the field.

To make this a balanced analysis, let’s see the if there are other points to consider. And to do that I’ll put on my traditional health IT hat, deformed and stained as it may be from having worked with EHRs and HIEs for more than a decade.

1. Workflows – Storage is fine. But what about the darn workflows that get/put things in that storage? The ER visit that needs access to your cloud-stored Medication will also need to reconcile them somewhere. And once that is done…. ahem…. in the EHR, it’ll probably need to be updated back in the cloud storage (perhaps Blue Button can help, but it’s not quite there yet in terms of adoption). My point is that without workflows, it’s a bit like taking your hard disk to work/vacation instead of laptop. And whether we like it or not, 95% workflows in healthcare today are done on incumbent EHRs. I’d like to see Box become vendor of choice for some of the multimillion enterprise EHR systems. Then we’ll really be making a dent.

2. Content ownership – Storage may assume clear ownership of what’s being stored. We wish, but it’s not that simple in healthcare. Some first-hand experiences at IDS like Kaiser have proved to me that DURSA is a synonym for chaos in healthcare. Is everything owned by the patient? Yes? Then why don’t all patients carry home their entire medical records? Perhaps it’s the hospital that owns it? Maybe the insurance company? The answer is anything you want it to be. What complicates it further are nuances like consent (which is a conundrum by itself) and state jurisdictions (Exhibit A – if the patient has Anthrax, which is state notifiable disease and a public health risk, the state owns the information regardless. Exhibit B – how to give break-the-glass type access during an emergency). My point is not that this is insurmountable. Only that the number of dials and knobs needed in a healthcare content dashboard and administration is an order of magnitude higher that any other industry.

3. Mobile access – This is where Box’s vision may shine. The inherent complexities and convolutions of healthcare may start to fade when tempted with the mobility value proposition. Your neighborhood endocrinologist values family dinners and golf outings as much as you. So anything that lets him/her easily get to the information he needs, will get traction. A platform that centralizes information and makes it available on-demand, in device-independent way will be appreciated. Incumbent systems like EHRs can have their own flavors (Exhibit A: Haiku) but we may still need a neutral party to do the data arbitrage with smart features like device pinning.

4. Collaboration – Sharing links not files, version control, discussion threads, tasks, etc. are worth doing in a consistent way across applications. So Box can bring value here too. But this featureset is less about technical prowess and more about business development. The more applications Box can bring to it’s platform, more sticky it becomes. Interoperability is undoubtedly the next frontier in healthcare IT, and everyone in the traditional industry is solving it using byzantine standards like IHE, HL7. Maybe there is a simpler way.

Ah, ‘Simple’. It’s uncanny how that word keeps coming up when talking about Box. Not all of it can be credited to its elegant offering though. I think the technology world around us has grown like foliage in an amazonian rainforest. Continuous barrage of super-specialized, hyper-ambitious offerings takes its cognitive toll. Try to browse the startup listings on AngelList, for example. Hybrid taglines (“Mint.com meets Groupon” is one) sound cool but I still have to repeat it few times to understand what the company does.

My point is that simple visions are starting to stand out. Maybe that’s why Box is such a media darling. It’s almost like we subconsciously want to believe that a simple approach to storage and content management makes sense. And may be it does. But it’s certainly not a panacea. I’d like celebrate Box’s move into healthcare, but not necessarily as a savior. Smart startups taking aim at healthcare bodes well in general.

Like in the 80’s Sun Microsystems made a splash with it’s prophetic tagline “Network is the computer“, I believe the next transformational wave in healthcare IT thinking is going to be about the network (read exchange, analytics, population). Time will tell if the cloud storage value proposition survives on it’s own in healthcare.

PS: Interestingly enough, it seems like Sun was considering “Network is the disk drive” as the slogan first, according to this article. Apparently that didn’t capture the intent. Not then, not now.

Zweena Health provides a service to collect real-world paper medical records, digitize them and enter it into a Healthvault account. That way users can have a Personal Health Record (PHR) created for them, without dealing with multiple bricks-and-mortar medical offices.

I’ve endorsed the validity of services offering such ‘last mile’ value propositions before. Note MotherKnows for getting pediatric medical records, Phrazer in the medical interpretation realm, etc. No doubt there is a need to fulfill here.

Couple of interesting things about Zweena Health. First, they store the digitized information in Microsoft Healthvault, and not in their own proprietary application. That’s smart because it adds a layer of disintermediation that could be a sell for the rare savvy PHR users. Better to store information in a more-recognized brand name platform than in a startup’s coffers. To me it also underscores the need for ubiquitous platforms in the Personal Health Record space. After Google Health’s untimely demise, seems like Healthvault is the de facto choice. Microsoft could definitely use some more competition.

The other interesting aspect is Zweena Health’s pricing model. It has three parts. First, there is a base monthly access fee ($10) which is to be expected in any subscription based service. Second are the copy charges which are no fault of Zweena Health. They are an absurd figment of conventional healthcare system, so still okay to pass on the the user. The third part is about ‘page bundles’ – a set number of pages that a user needs to buy on Zweena Health. I find that to be an archaic way of thinking about digital information. The bloated paper records, when retrieved, should be parsed into discrete information that is in bits and bytes. So why should the payment be modeled on paper units? What if a provider took 3 pages to describe a simple procedure or left one blank intentionally? Sadly, this is the part where a new-age idea seems to be bogged down by antiquated processes. PHRs continue to be a valid need that hasn’t been solved to any shred of viability. Sigh.

When EHRs started showing up on the mainstream industry radar a couple of decades ago, everyone focused on how they helped get rid of the archaic paper records and digitized care delivery within organizations. How time changes perspective. Now EHRs are somewhat commodity and local, intra-organization workflow digitization is a bit passé. The buzz now are inter-organization workflows and health information exchange.

Within the conventional realm of EHRs, attention was given to modules that emulated real-world clinical workflows like order entry (as CPOE), medication administration (as eMAR), etc. But with interoperability as the next frontier, we are seeing new solutions that tackle hitherto unrecognized/under-appreciated healthcare information topics. One such topic is consent management.

If you think consent is just a simple boolean flag that needs to get stored in a table somewhere, think again. Consent is a surprisingly complex multifactorial concept that is mired in vague laws that differ from state-to-state, but needs to be implemented accurately as a gatekeeper for critical information. Consider the following examples of what all needs to be factored into consent management:

Consent can be of different types: consent to disclose information, consent to access information

Consent can be given at different levels: provider, group, region, state, HIE

Consent can have different implementations: full opt-in, full opt-out, opt-in with restrictions, opt-out with exceptions

There are different workflows that interact and over-ride consent: like ‘break-the-glass’ functionality that lets certain providers access information in case of emergency

Consent is governed by different laws vary by state: For example, in NY a minor (<18 years) can receive certain reproductive, mental health services regardless of their parent’s consent. So the consent management software has to not only track the parental consent but also the child’ birth date, procedure/diagnosis and reconcile them constantly

Other thorny questions: time range applicable to consent (can/should it be retrospectively applied? what about reports that have been produced before patient chose to opt-out?), public health considerations (does the state own information about critical communicable diseases irrespective of consent?), what to default to if consent is unknown (opt-in? out? restricted?), how to handle conflicts between systems that claim to have consent, etc.

This paper by ONC is a good summary of most of the nuances related to consent. It’s no small feat for a Healthcare IT vendor to manifest nation-wide consent management as software artifacts, esp. if they have to retroactively fit it into legacy offerings. Which brings me to Health Information Protection And Associated Technologies (HIPAAT). They provide consent management and auditing software to enable health information privacy for various healthcare participants. What makes them unique is that they are the only vendor I know of that does nothing but that.

The core HIPAAT product seems to be ‘Privacy eSuite’ (PeS), which is essentially a consent validation and management SaaS offering that can be implemented by EHRs, HIEs and stand-alone care organizations. PeS would help its customers implement consent workflows like break-the-glass functionality in their native applications. Other interesting products are myConsentMinder (a consumer-oriented web application that helps patients self-manage consent) and the IHE-ATNA compliant Universal Audit Repository (stores and implements PHI-related auditing capabilities).

HIPAAT is another example of my previous point about healthcare IT excellence emerging in narrow niches. Traditional market solutions are getting bloated because they are trying to do too many things. Superlative marketing and regulatory anxiety are muddying the field by encouraging cross-dressing. EHRs are trying to claim interoperability features (e.g. Epic’s abysmal failure called Care Elsewhere) and HIEs are trying to do EHR work (e.g. Axolotl’s EMR lite and Medicity‘s ProAccess).

I’m a bit pessimist about the near future being kind to niche solutions. I think most of these one-trick-ponies are going to get acquired by richer incumbents. Specially the incumbents enjoying the cross-subsidy of their parent conglomerates, like Medicity (owned by insurer Aetna), McKesson (main business is drug distribution) or GE (truly diversified). But once the market zeal for inorganic growth slows down, the once remaining will be having a genuine value proposition that is worth paying for. And I bet that will be a more focused set of survivors who do a few things, but do them right.

Among other things in healthcare, the care transition process is also broken. For example, outpatient care usually ends with the provider summarizing for the patient their medical issue, instructions on next steps, etc. Ideally, the key takeaways are given to the patient as printed handouts, prescription instructions. But as most of us who have been a patient would know that printed medical artifacts are cryptic and conversational details fade away rather quickly. So for a recently diagnosed Crohn’s Disease patient, the label on prescription may inform about corticosteroid treatment details but remembering doctor’s talk about it’s cause, lifestyle changes, treatment options etc. is not easy.

Jiff is a company that is focusing on ‘reinventing healthcare communications’ (their own words). They seem to have two offerings to that effect so far- JiffPad, and Circle of Health. JiffPad is an iPad app that allows annotations and notes to be overlaid on educational content and sent back/forth between provider and patient. Circles of Health allows the creation of niche social health networks around an individual so caregivers can educate and collaborate (like CareFlash). The apps are free for patient, but Jiff plans to make money from providers through app licenses, storage space (!) and possibly sponsored content.

With that background, the ‘reinventing healthcare communication’ mission of Jiff makes sense. It’s a lofty goal though, since there are multiple incumbent players who own the digital workflow that Jiff is intending to lubricate. Exhibit A – EHR offerings. Where do the physician/nurse documentation (like H&P, Progress Note, Discharge Instructions..) live today? EHR is not only the easy answer, it’s the legal answer. So unless provider annotations on JiffPad are integrated into the EHR workflow and considered part of the medico-legal record, they create yet another silo of information. Beautiful, user-friendly, cool iPad app. But on it’s own isolated digital island.

Exhibit B – PHR offerings. Personal Health Record space may not have a clear winner, but it certainly has a growing number of players in the game. Neutral platforms like Microsoft Healthvault and Indivo along with EHR-tethered or insurer-sponsored offerings are all vying to be the patient’s personal health record. Unless Jiff plans to be yet another PHR platform in the fray, integration is needed at this end too.

Exhibit C – HIE, ACO offerings. One of the reasons for creating complex geo-political health information exchanges is to be able to engage patients in their own care. If ACOs are going to make a buck from bundled payment model, they need to make sure patients are involved in their own care. Other drivers like Direct Project based messaging (the ‘how’) and Meaningful Use (the ‘why’) are emerging as well. All of these are rooted in the clinical information/workflow that is generated by EHRs and other point-of-care tools. Again, Jiff platform needs to find it’s footing in real clinical or administrative workflow to be viable long-term.

I rest my case for high barrier to entry. If Jiff can re-state their mission to be about ‘care coordination’ rather than communication, there is scope for a new entrant. Inpatient discharge, palliative care, oncology services… there are numerous care transition points where better communication is key to better outcomes. A compelling offering across care settings that is well integrated with local workflow systems would fly off the shelves.

I admire all startups. Esp. the ones with the cojones to take on established, orthodox players. But as I read this quasi-cheerleading post about Jiff, I feel that the romance between healthcare and tech entrepreneurs has reached a feverish pitch. Yes, conventional healthcare software artifacts are ugly, inefficient and low-tech. But not because healthcare professionals want them that way. There are legal, political, real-world constraints in care delivery because medicine is an art, not a perfect science. Unless the disruption is from or with the players that own the underlying digital workflow (like EHRs), it’s prognosis is not good.

There is no denying that the usability of current EHRs sucks. More pointedly, the data entry is really excruciating. Blogs have been devoted to the rants, articles have been written. In fact, the problem is so real that entrenched luddites have spawned a cottageindustry of ‘Medical Scribes‘ – hired hands who do nothing but take physician’s narrative and punch the keys on the keyboard to get it in the dang EHR. Regrettably, industry behemoth AMA‘s position seems to be that of fascinated enthusiasm, as noted in this article. So instead of either training clinicians better or mounting pressure on vendors to create better user interface, we are contributing to the mindless expansion of peripheral careers that add cost to the overall system.

Perhaps the solution is, as noted in this THCB post, “..to sprinkle some kind of pixie dust on the EHR” to make the data entry work. Tonic Health is a data collection management platform that can created user-friendly screens that are easy to interact with. The collection templates or forms can be customized, and made intelligent based on rules. Note that the offering is tailored for patient engagement only, not for clinician’s data entry. The screenshots look like it may have an element of gaming at some places.

Like everywhere else in healthcare IT, there is competition in data entry solutions. Most of it focuses on physician data entry woes, and has some speech recognition and NLP technology at it’s core. Prominent examples are Health Fidelity (based on Columbia’s MedLEE engine), Medicomp, MD-IT, etc. Another interesting overlap is with proprietary patient engagement tablet maker Phreesia. Seems like Tonic Health on iPad is going to eat into Phreesia’s value proposition.

Patient data entry or clinician’s, the Achilles heel is whether data gets back into the local incumbent- the ugly EHR. What matters is the back-end integration with EHR vendors, without which the data is trapped in yet another silo, non-actionable. I’d be a much bigger fan (and believer) if Tonic Health had info on EHR Partners front and center on their website. Also, if/once those inroads are made, why not move into solving data entry grievances for clinicians… that may be a more viable business model.

A startup that helps you access and retain your medical records (to which you are entitled) from providers. Another proof of how impenetrable and complex our healthcare system is.

It’s a brilliant niche. MotherKnows will interact with the healthcare system (your physician, hospital, insurer, etc.) on your behalf to procure a copy of the medical record, store it, analyze it and make the information available to you on-demand. Anyone who has tried getting their child’s immunization record will agree that the conventional interaction is a sub-optimal customer service experience at best. So having someone else do it for you is worth paying for.

Once collected, the information is available in a PHR manner – view meds, problems, allergies, immunizations, growth charts in one place; create emergency cards; get reminders; mobile access, etc. But the key to MotherKnows’ viability, in my view, is being the authorized agent for painful extraction of medical records. As long as the pricing is right (which, at $19-$98/year, is in the right range) it will gain traction.

It’s a prudent strategy to market it initially to parents as a way to keep the records straight for their precious progeny. But I don’t see why it can’t be extended to adult healthcare consumers themselves. I’d like to be able to get my medical data all in one place, hopefully showing me trends found in my quasi-annual physical exams and labs. Today in the patient population, the motivated few try to save copies of records; and the enlightened few go one step further and manually key the data into an online PHR like Healthvault. In either case manual labor and discipline is required. Perhaps having a real-world service (of paper record collection) is what really can make a difference to PHR uptake by consumers. Hopefully, MotherKnows will reach beyond just child medical records in future.

The overall idea of patients paying an agency to wrest to their medical records from providers point to the underlying systemic inefficiencies. Theoretically, there are solutions on the horizon. An enterprise EHR used by care providers could pass the relevant info into a PHR accessible by patients. And if they change providers, a community-wide Health Information Exchange (HIE) could still enable patients to be the custodian of thier own information in another system. But we are not there yet.

The unmet need for electronic systems (like PHRs) to interface with the physical world (i.e. bricks and mortar organizations and paper processes) is very real. Till every end-point in healthcare delivery is digitized and interoperability is no longer a pipe dream, we’ll need services that handle real-world complexities. Take companies like eHGT who are already in this ‘record retrieval services‘ niche. By actually having real account managers who can get imaging records from facilities, they elevate the value proposition of an “Image Exchange” to new level. The phenomenon exists outside of healthcare too. The now defunct Random Acts of Genealogical Kindness (RAOGK) site was a volunteer effort to bridge the gap between virtual demand and physical supply of genealogy records.